Dr Augustino Hellar’s journey into surgery was shaped by his upbringing in Tanzania, where access to healthcare was often limited. He recalls how long distances to health facilities were a common barrier.
“I saw the disparity in health care, especially for rural communities,” he said. “It was not uncommon to find patients having to travel maybe 10 kilometres away to find health services.”
The reality Dr Hellar witnessed as a child is not unique to Tanzania. It reflects a crisis playing out across the African continent. Around 5 billion people, roughly two-thirds of the world’s population, lack access to safe, affordable surgical care. Africa bears a disproportionate share of that burden, served by just 2% of the world’s surgical workforce. Surgeon-to-population ratios across East, Central and Southern Africa average around 0.59 per 100,000 people. This is far below any accepted global benchmark.
To meet the 143 million surgeries estimated to be needed annually in low- and middle-income countries, the world would require 2.2 million additional surgeons. This shortage contributes to unmet surgical needs, including congenital conditions that Operation Smile addresses.
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Dr Hellar did not have to read about this crisis in a textbook; he lived it.
That experience drew him toward medicine, and within medicine, toward surgery. Today, as Operation Smile’s Regional Director for Rwanda, Ghana, and Tanzania, Dr Hellar is at the forefront of efforts to close the gap in access to safe surgery across the continent. The organization currently operates in 10 countries in sub-Saharan Africa, including Ethiopia, the Democratic Republic of Congo, Malawi, South Africa, Kenya, Madagascar, Mozambique, Rwanda, Ghana, and Tanzania.
He described the organization’s work as built on four interconnected pillars.
The first is service delivery: providing comprehensive cleft care for patients with cleft lip and palate. The second is workforce development, training surgeons, anaesthesiologists, and the full multidisciplinary surgical team in partnership with ministries of health and universities. The third is infrastructure strengthening, helping surgical teams work in safe, adequately equipped environments. The fourth operates at the community level, working with community health workers to ensure patients who need care are identified and reach services.
The COSECSA partnership
A key part of Operation Smile’s strategy to strengthen surgical systems is its partnership with the College of Surgeons of East, Central and Southern Africa (COSECSA), one of the largest surgical training institutions in the region.
Dr Hellar said that the partnership was a logical one.
He said that COSECSA’s decentralized training model allows doctors to train within accredited local hospitals rather than relocating to universities.
“With COSECSA, it’s probably much better than university-based programmes,” he said, “because they are trained in their local settings. It’s someone who has grown up probably in this community, and they’re training there. So there’s more motivation to be able to stay and offer their services.”
This is an approach that helps retain talent within communities.
“One of the things that is a plus for this training body is that you don’t have to go to the university. It’s a fellowship programme. You can train in any hospital that is accredited by COSECSA,” he said. That local grounding, he argues, is also a partial answer to the persistent problem of brain drain, the loss of African-trained medical professionals to better-resourced health systems elsewhere.
He also said that the model enables cross-country collaboration and skills exchange.
Rwanda – A blueprint for the continent
Of the three countries in his portfolio, Rwanda is the one Dr Hellar points to most readily as a model for others to follow. The country has developed what he describes as a hub-and-spoke model of surgical care – one in which the capacity to treat patients is distributed across district-level facilities, not concentrated only in the capital.
“That is something that should be replicated in other countries… because it increases surgical access,” Dr Hellar said.
Rwanda’s strategy, as he described it, is to ensure that patients can access care within a two-hour journey or a 75-kilometre radius of where they live. It is an ambitious benchmark and one he believes should become the standard across sub-Saharan Africa.
He also pointed to strong government leadership as a critical success factor.
“One of the things that we’re seeing in Rwanda is the government leadership, the Ministry of Health, taking the lead. It’s very strong in Rwanda, and I think that is something that other countries can also learn from,” he said.
The government engagement was evident in early 2025, when Operation Smile convened the first Pan-African Surgical Conference in Kigali, alongside Rwanda’s Ministry of Health, the Surgical Society and the University of Rwanda. The five-day event brought together more than 500 surgeons, policymakers and health workers from 36 countries to work toward practical solutions for expanding surgical access across the region.
Despite progress, significant challenges remain.
Dr Hellar identified five major challenges in delivering surgical care across the African continent.
The first and largest is the surgical workforce itself. “We have very few surgeons, anaesthesiologists, nurses who are working in the surgical space,” he said. “That is one of the biggest challenges.” However, training partnerships like the COSECSA collaboration are the primary lever for addressing this.
The second is infrastructure, particularly at district and community-level facilities. “Maybe in the major cities you find hospitals that are well-equipped, but if you go down to the district level, you have limited theatre space, ICU capacity, equipment challenges,” he explained.
Third is late patient presentation. This is the tendency for patients to arrive at facilities with conditions that have progressed far beyond what early intervention could have addressed. This, he said, is itself a consequence of poor access. “Patients tend to present late because probably they don’t have access to easily-reached care,” he said, calling for stronger community awareness campaigns and referral systems.
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Fourth is the supply chain. “We have weak supply chain systems,” he said. He added that working with governments to develop targeted partnerships is part of the solution.
The fifth barrier is financial. Across sub-Saharan Africa, large numbers of rural patients lack health insurance and cannot afford the cost of surgical care. “Trying to find innovative ways, like universal health access, to support financing mechanisms for healthcare is something that is quite needed,” said Dr Hellar.
A vision for African surgery
Dr Hellar’s vision for the future of surgical care across Africa is articulated in terms of what patients should no longer have to endure.
“One of the biggest things that I would wish to see in the future is increased access to care… Patients do not have to spend days… they do not have to become poor because they sell their cows, sell their houses… so that they can afford surgical care,” he said.
His vision is to ensure that surgical services are available within a radius of 75 kilometres, in sub-Saharan Africa, using a hub-and-spoke model pioneered in Rwanda.
“If that is achieved across sub-Saharan Africa… it will decrease the surgical burden and impact of surgical mortalities and morbidities,” said Dr Hellar.
